Vaginal Birth After Previous

 Cesarean Delivery

By Lisa L. Dyer, M.D., MPH

VBAC or vaginal birth after previous cesarean delivery was commonplace for many years because published evidence suggested that the benefits of VBAC outweighed the risks in most women with a prior low-transverse cesarean delivery.

Recently, it has become apparent that there is a small but significant risk of uterine rupture in VBAC patients, the result of which can be catastrophic to the mother and the baby. Uterine rupture can result in rapid profuse intraabdominal hemorrhage, which can lead to the need for hysterectomy, DIC and the associated complications, and the need for transfusion. Furthermore uterine rupture can cause abrupt cessation of blood supply to the baby, which can lead to hypoxia. Every minute geometrically increases the risks to both the mother and the baby, so the obstetric team must mobilize immediately. Even with the most rapid and efficient of responses poor outcomes can occur. Conversely some uterine rupture cases are associated with excellent outcomes for mother and baby.

Increasingly these adverse events have become associated with malpractice suits. New guidelines also have been suggested with respect to managing VBAC patients. For example, ACOG (American College of Obstetricians and Gynecologists) now recommends that physicians be “immediately available” throughout active labor, capable of monitoring labor and performing an emergency cesarean delivery. This is interpreted to mean the physician is “in the house” when a VBAC patient is in labor. This is difficult in a community hospital setting where most physicians see patients in their off-site offices while their labor patients are in the hospital. Consequently many physicians no longer offer VBACs to their patients because the time constraints of in-hospital coverage are onerous. Furthermore, induction of labor is almost never offered to patients with prior cesarean sections because the risk of uterine rupture is even greater. Interestingly the success of VBAC has not changed, but the overall number of VBACs being done is continuing to rapidly decline.

The recommendation for physicians to be “immediately available” also has led to the provision of “in-hospital” coverage generally subsidized by the hospital. Many community hospitals now have 24-hour OB hospitalists to meet these guidelines. This may become standard of care in the future. The financial implications of this provision can be as little as $500,000 a year to as much as $1,000,000 when providing for both obstetric and anesthesia coverage. This is particularly onerous for community hospitals that may do less than five VBACs per month.

Most women with one previous low-transverse cesarean delivery are candidates for VBAC and should be counseled regarding the risks, including uterine rupture and offered a trial of labor. However physicians may be increasingly reluctant to provide this service secondary to onerous monitoring requirements and high liability issues. All obstetricians are acutely aware that even if the standard of care is followed and there are no grounds for a malpractice suit, if a bad outcome occurs, successful litigation by the plaintiff is possible. The incidence of uterine rupture in the absence of induction on a low-transverse uterine incision is less than 1 percent. 

Dr. Dyer practices obstetrics and gynecology in Burlingame.